Sam’s father Scott Morrish said: “The thing that we’re still trying to push for is, we’re not clear who the ombudsman is accountable to, we’re not clear who really understands what happens behind the scenes there, and we’re not entirely sure that Parliament is actually able to look at anything more than what comes out in the report.”

Dame Julie said: “I accept that the family are right that the investigation method used in this case was not adequate to the complexity of the case.

“I really recognise that this contributed to the family’s distress and we have apologised for that and thanked the family for their feedback on the particular method we used in this case, because we are developing new investigation methods.”

Dame Julie said that Sam’s devastated family suffered “further injustice” because health officials failed to properly investigate the youngster’s death.

“But this case has to be looked at in the context of taking on over 4,000 cases to investigate every year, and receiving very few complaints about the quality of our decision making.

“When we do, we treat it like gold dust to help us improve our service.

“We’ve published this case so that the wider NHS learns from Sam’s death,” she added.

NHS England was ordered to pay £20,000 to the family.

Mr Morrish said: “The irony is we never wanted to lodge a formal complaint.

“We only did because we were advised to by the Patients Association in response to the NHS completely getting it wrong, not once, but twice.

“We didn’t want it to be about blame, we wanted it to result in good learning.”

Who are we? Get to know our CEO, Neil Fearn, on our handy website guide. Neil has been working in the clinical negligence industry for 25 years and specialises in claims involving complex and serious injuries mainly arising out of Obstetric Care
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